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Our chronic disease care ain’t #1

August 10, 2011 at 9:28 am

Aaron Carroll

Yesterday, I highlighted a Commonwealth Study comparing twelve industrialized nations to show how we’re paying more for the same drugs. Today, I want to point out some other findings related to quality. Specifically, I want to show you some data related to how well we care for chronic diseases.

One of my longstanding complaints about the US health care system is how we focus so heavily on really bad, but relatively rare things. We will do anything it seems to prevent a death from happening, but we will often ignore primary care, public health, and chronic disease ambulatory care. That’s penny-wise and pound foolish, and it bears out in comparative data.

When we don’t care properly for people with chronic diseases on an ongoing basis, they get sick. Then, they need to get admitted to the hospital. That’s expensive, and often avoidable. So a well-functioning health care system will work to prevent admissions for chronic diseases. And, in this, we fail:

That’s the number of people over age 15 per 100,000 pop who had to be admitted to the hospital for their asthma in 2007. We’re not even close to doing well, let alone being number one. And it’s not just asthma. Here’s hospitalizations for congestive heart failure:

Similarly bad. That’s two different organ systems, two different diseases, two different examples of how we’re doing pretty badly at preventing hospital admissions, which costs money and leads to bad outcomes.

But that wasn’t even the worst thing I saw in the report. That prize goes to diabetes. You see, if you don’t take care of your diabetes properly, over time you can get really bad complications. You can have eye problems, or kidney problems, or circulation problems. Sometimes these get so bad, then lead to non-healing wounds which result in amputations. Obviously, this is a complication you don’t want. Yet, here are lower extremity amputations due to diabetes:

That’s so bad, I don’t even know where to start. We’re an obese country, and we have more diabetes than most other countries, but this is a preventable outcome. And we’re doing really, really badly.

When we brag, we consistently stick to the same things. Rare transplants, survival rates of cherry-picked cancers, and other aspects of the system that don’t relate to outcomes. But this is the stuff that often matters: common chronic diseases that require ongoing care and a well-functioning health care system. We don’t have that system, and it shows.

Exactly the stats for the problem, now the rationale: in our Health Value AcceleratorTM findings (online tool for assessment of employer-employee engagement), the results are staggering: we are seeing millions of dollars paid but engagement quite low. WAKE UP–demand outcomes-based and shared risk contracts. Nothing less will do
Cyndy Nayer

In another post you wrote [on breast cancer]::
The mortality rates? The American Cancer Society’s Cancer Facts & Figures 2009 reports it’s 25.0 per 100,000 women in the US and Cancer Research UK reports it’s 26.7 per 100,000 women in England. That’s not as big a difference. Hard to believe we’re spending almost two and a half times per person for health care what they do over there.

Another statistic to look at would be the average age of death from cancer by country.

What is the incidence of these things across countries? Patient adherence to what the doctor recommends? These aggregate statistics are interesting but we need much more rigor and detailed information to really get at the impact of our health care system vs other factors.

The diabetes amputation chart – it doesn’t seem to be normalized for the number of diabetics. Sure, we have a problem with diabetes in the US, but folding that statistic into a discussion of the relative inefficiencies of different health care systems just adds confusion. Perhaps a amputees per X number diabetics comparison would more useful?

Wiki says: “White Americans (non-Hispanic/Latino and Hispanic/Latino) are the racial majority, with an 80% share of the U.S. population, per official estimates from the Population Estimates Program (PEP)”

This strikes me as bullying. It is not a foregone conclusion what is “more accurate”. Adjusting by one variable is far from a complete adjustment. Maybe adjusting by another variable throws the whole thing the other way. You can’t actually do anything like “full adjustment” due to unobservables, lack of data, and insufficient sample. For these reasons, all international comparisons are in service to, essentially, qualitative conclusions. Besides, haven’t you already spelled out what it looks like with your preferred adjustment? So, the record is complete on this, yes?

Aaron has shown the data and told you where to get them. If you want to present the data in another way, I urge you to do so on your own blog. Having said that, Aaron may do as he wishes here, of course.

Bullying? I’m just asking if he was going to update this now that additional data is available that renders the initial post very misleading. For me personally, if someone pointed out an omission in data I presented I would correct it, which is why I asked.

Of course this is not a complete adjustment that has accounted for every possible variable. If there are other variables that are relevant and for which we have data available, let’s dig into those too. But the absence of that doesn’t change the fact that the initial metric was flawed.

I mean, Aaron even alluded to the importance of varying rates of incidence in the post, but did not measure the impact that they had. To assert that the quality of US diabetes and asthma care is poor based on admits/amputations without accounting for those varying rates is a glaring omission.

All else equal, admits as a percentage of asthmatics is a more accurate descriptor of the quality of our asthma care than admits as a percentage of total population, do you disagree with that?

Our chronic disease care definitely needs all the help it can get. I work with Good Days from Chronic Disease Fund, and it is our goal to assist chronic disease sufferers in gaining the treatment they need. By supporting our organization, you could help these patients too! http://www.gooddaysfromcdf.org/